Image-Guided IORT after Surgical Resection of Brain Malignancies: A Feasibility Study

PURPOSE/OBJECTIVE(S)

Intraoperative radiation therapy (IORT) can be used to locally apply radiation doses to surgical cavities of resected brain metastases and glioblastoma. The miniaturized linear accelerator INTRABEAM 600® offers a low-energy system of 50kV X-rays. To date, placing the spherical applicator in the surgical bed has been done manually and without final positioning verification. Ultimately, without positional control, it must be assumed that the applicator is optimally positioned against the tissue in the tumor cavity, without any air interference or fluid underlying. Misplacements could lead to incomplete dose delivery, potentially yielding an increased risk of recurrence. Therefore, we deemed relevant to assess intraoperative imaging as a novel option for easing the applicator positioning.

MATERIALS/METHODS

A surgical environment was mimicked in two test runs with an interdisciplinary team, accounting for operating and anesthesia times. The IORT planning software Radiance (GMV Innovating Solutions, Madrid, Spain) was previously calibrated with a "cheese" phantom, using twelve different density levels from 0.3 to 1.842 g/cm3, yielding a value-to-density table with -600 to +600 HU range. Furthermore, two inserts were placed in the phantom to evaluate the quality and spatial resolution of the cone-beam CT (CBCT) imaging. The O-Arm System (Medtronic, Minneapolis, MN, USA) was employed for acquiring tomographic intraoperative imaging, once the applicator was placed in a skull-shaped phantom. Two expert radiation oncologists contoured the acquired dataset and performed the treatment calculations, based on a 30 Gy prescription dose.

RESULTS

We achieved the best possible CBCT imaging quality with the 120kV and 20mA setting parameters. This corresponds to the "HD3D (large)" O-Arm setting mode. With this, the image quality with artifact reduction, minimization of image noise and consideration of a low radiation exposure of only 0.5mSv for the patients is feasible. Approximately 15 additional minutes were accounted for contouring and planning times.

CONCLUSION

Good-quality intraoperative imaging can be obtained when performing IORT, easing the applicator positioning and resulting in a more precise target irradiation. Operating times would be minimally extended with this procedure. A clinical study will initiate based on these findings.

Hopping frequency influences elastic energy reuse with joint series elastic actuators

Robotic limb design struggles to combine energy efficiency with human-like levels of movement versatility. High efficiency and a range of angles and torques are characteristics of human hopping at different frequencies. Humans use muscles in combination with tendons to achieve the required joint actuation. Therefore, we consider whether appropriately tuned series elastic actuators (SEAs) placed at the leg joints can be used to reduce the functional gap between robots and humans. Human hip, knee, and ankle biomechanics were recorded over a range of hopping frequencies to extract joint angles and torques, which were used as an input to a mechanical simulation SEA model. This model was used to optimize the SEA stiffness of each joint to either minimize peak power or energy requirements. This work investigated the relationship between hopping frequency and SEA stiffness, the utility of using SEAs at each joint, and the reasons behind humans' preferred hopping frequency. Although the constant stiffness values across different hopping frequencies are suitable for the knee and the ankle, a variable serial elastic actuator stiffness could still further reduce energy requirements. Optimal SEA stiffness was found to reduce peak power requirements by up to 73% at the ankle and up to 66% at the knee, with greatest benefits found around the preferred frequency. However, no SEA benefits were found for the hip and above the preferred hopping frequency for the knee. These insights could be used to aid in the design of robotic and assistive devices to achieve versatile and energy efficient human-like movements.

Assistance magnitude versus metabolic cost reductions for a tethered multiarticular soft exosuit

When defining requirements for any wearable robot for walking assistance, it is important to maximize the user's metabolic benefit resulting from the exosuit assistance while limiting the metabolic penalty of carrying the system's mass. Thus, the aim of this study was to isolate and characterize the relationship between assistance magnitude and the metabolic cost of walking while also examining changes to the wearer's underlying gait mechanics. The study was performed with a tethered multiarticular soft exosuit during normal walking, where assistance was directly applied at the ankle joint and indirectly at the hip due to a textile architecture. The exosuit controller was designed such that the delivered torque profile at the ankle joint approximated that of the biological torque during normal walking. Seven participants walked on a treadmill at 1.5 meters per second under one unpowered and four powered conditions, where the peak moment applied at the ankle joint was varied from about 10 to 38% of biological ankle moment (equivalent to an applied force of 18.7 to 75.0% of body weight). Results showed that, with increasing exosuit assistance, net metabolic rate continually decreased within the tested range. When maximum assistance was applied, the metabolic rate of walking was reduced by 22.83 ± 3.17% relative to the powered-off condition (mean ± SEM).

Measurement of biomechanical interactions at the stump-socket interface in lower limb prostheses

This paper introduces a novel measuring approach for detecting relative movement between stump and socket in lower limb prostheses. The application of the motion capturing based measuring approach is shown at a single male trans-tibial amputee using a Patella Tendon Bearing (PTB) socket. It further investigates and assesses the feasibility of measuring the relative movement between stump and socket during level walking at different velocities and allocating it to the coinciding loads. Representative results for the two translational degrees of freedom in the sagittal plane are presented and discussed. For the proximodistal (pd) direction, a linear correlation between applied load and relative movement is found, while for the anteroposterior (ap) direction the stump movement is largely influenced by the motion sequence during the respective gait event. Additionally, the effect of walking speed is discussed.

Sunny with a chance of gastroenteritis: predicting swimmer risk at California beaches

Traditional beach management that uses concentrations of cultivatable fecal indicator bacteria (FIB) may lead to delayed notification of unsafe swimming conditions. Predictive, nowcast models of beach water quality may help reduce beach management errors and enhance protection of public health. This study compares performances of five different types of statistical, data-driven predictive models: multiple linear regression model, binary logistic regression model, partial least-squares regression model, artificial neural network, and classification tree, in predicting advisories due to FIB contamination at 25 beaches along the California coastline. Classification tree and the binary logistic regression model with threshold tuning are consistently the best performing model types for California beaches. Beaches with good performing models usually have a rainfall/flow related dominating factor affecting beach water quality, while beaches having a deteriorating water quality trend or low FIB exceedance rates are less likely to have a good performing model. This study identifies circumstances when predictive models are the most effective, and suggests that using predictive models for public notification of unsafe swimming conditions may improve public health protection at California beaches relative to current practices.

Predicting water quality at Santa Monica Beach: evaluation of five different models for public notification of unsafe swimming conditions

Bathing beaches are monitored for fecal indicator bacteria (FIB) to protect swimmers from unsafe conditions. However, FIB assays take ∼24 h and water quality conditions can change dramatically in that time, so unsafe conditions cannot presently be identified in a timely manner. Statistical, data-driven predictive models use information on environmental conditions (i.e., rainfall, turbidity) to provide nowcasts of FIB concentrations. Their ability to predict real time FIB concentrations can make them more accurate at identifying unsafe conditions than the current method of using day or older FIB measurements. Predictive models are used in the Great Lakes, Hong Kong, and Scotland for beach management, but they are presently not used in California - the location of some of the world's most popular beaches. California beaches are unique as point source pollution has generally been mitigated, the summer bathing season receives little to no rainfall, and in situ measurements of turbidity and salinity are not readily available. These characteristics may make modeling FIB difficult, as many current FIB models rely heavily on rainfall or salinity. The current study investigates the potential for FIB models to predict water quality at a quintessential California Beach: Santa Monica Beach. This study compares the performance of five predictive models, multiple linear regression model, binary logistic regression model, partial least square regression model, artificial neural network, and classification tree, to predict concentrations of summertime fecal coliform and enterococci concentrations. Past measurements of bacterial concentration, storm drain condition, and tide level are found to be critical factors in the predictive models. The models perform better than the current beach management method. The classification tree models perform the best; for example they correctly predict 42% of beach postings due to fecal coliform exceedances during model validation, as compared to 28% by the current method. Artificial neural network is the second best model which minimizes the number of incorrect beach postings. The binary logistic regression model also gives promising results, comparable to classification tree, by adjusting the posting decision thresholds to maximize correct beach postings. This study indicates that predictive models hold promise as a beach management tool at Santa Monica Beach. However, there are opportunities to further refine predictive models.

Quantifying the non-fungicidal effects of foliar applications of fluxapyroxad (Xemium) on stomatal conductance, water use efficiency and yield in winter wheat

The active ingredient fluxapyroxad belongs to the chemical group of carboxamides and is a new generation succinate dehydrogenase inhibitor (SDHI) in complex II of the mitochondrial respiratory chain. It has strong efficacy against the key foliar diseases of winter wheat in the UK: Septoria leaf blotch, yellow stripe rust and brown rust. Fluxapyroxad is marketed under the brand name of Xemium, was launched in 2012 and is available in the UK as a solo product (Imtrex) for co-application with triazoles, in co-formulation with epoxiconazole (Adexar), or in a three way formulation with epoxiconazole and pyraclostrobin (Ceriax). The objective of the study was to quantify the direct effects of Xemium on stomatal conductance and yield, mediated through stimulation of host physiology. Three field experiments and two controlled environment (CE) experiments were conducted across three cropping seasons (2010-2012) in Herefordshire and Cambridge, in the UK. Xemium was evaluated against boscalid, pyraclostrobin (F500), epoxiconazole and an untreated control. Across site-seasons, disease severity was significantly reduced when Xemium was applied as a foliar spray. Healthy canopy size and duration was increased by Xemium and canopy greening effects were seen shortly after application. Stomatal conductance was found to be consistently lower in Xemium treated plants but reduced stomatal opening was not found to be detrimental to yield in these experiments. Large, beneficial effects of Xemium on water use efficiency were found at the canopy level and this finding was supported by measurements of instantaneous water use efficiency at the leaf level. Effects on season long water use efficiency were largely driven by improvements in yield for a given amount of water uptake. Foliar applications of Xemium reduced the water required to produce 1.0 t grain per hectare by 82,330 L(82 t) when compared with an untreated crop. Yield was significantly higher in Xemium treatments and this was achieved primarily through increases in grains ear. Evidence is presented hereto show that in addition to controlling visible disease symptoms, Xemium is able to exert positive physiological effects on the host. The yield increase from plots treated with Xemium applied at standard commercial timings was shown to exceed that which can be explained solely through good disease control and the associated loss of healthy canopy area. Approximately 1.0 t ha(-1) (12%) yield was produced by Xemium treatments which could not be accounted for through the control of visible disease symptoms.

Analytical approaches to uptake and release of hydrogel-associated FGF-2

Strategies to control the delivery of growth factors are critically important in the design of advanced biomaterials. In this study we investigated the binding and release of fibroblast growth factor 2 (FGF-2) to/from a biohybrid hydrogel matrix by four independent analytical methods: radioisotope and fluorescence labeling, amino acid analysis and Enzyme-Linked Immunosorbent Assays (ELISA). The compared analyses provided qualitatively similar uptake characteristics while the results of the FGF-2 quantification strongly depended on the particular experimental conditions. The release kinetics of FGF-2 from the gels could be monitored sensitively by (125)I labeling and by ELISA-techniques. The latter method was concluded to be advantageous since it permits the application of unmodified ("native") growth factors.

Fibrillar collagen assembled in the presence of glycosaminoglycans to constitute bioartificial stem cell niches in vitro

Fibrillar collagen was reconstituted from mixtures of monomeric tropocollagen and heparin or hyaluronic acid, respectively. Turbidity measurements were utilized to follow the fibrillar assembly and demonstrated the influence of the concentration of the glycosaminoglycan on the maximum optical densities. Thin film coatings of maleic anhydride copolymers were utilized for the covalent immobilization of the fibrillar assemblies to solid supports. Quantification of surface-bound collagen was accomplished by ellipsometry and HPLC-based amino acid analysis indicating that less collagen was immobilized in the presence of the glycosaminoglycans. SEM and AFM revealed various sizes and shapes of the immobilized fibrillar assemblies if collagen fibrils were prepared in the presence of heparin or hyaluronic acid. Human hematopoietic stem cells (HSCs) were cultivated on the surface-bound collagen fibrils and the migration of adherent cells was studied by time-lapse microscopy. Migration rates on fibrillar structures were significantly lower then on tropocollagen indicating a more intimate contact of HSCs to the fibrillar substrates.

Adverse effects of captopril in hospital outpatients with hypertension

Hypertensive patients prescribed captopril while attending a hospital hypertension clinic were studied, to identify the benefits of the drug, its adverse effects and factors predisposing to them. One hundred and eighty two patients were followed for a mean of 18 months; 24 received captopril alone, and 158 combinations of captopril and other antihypertensive drugs, especially loop diuretics (91/158), or thiazide diuretics (57/158), or other vasodilators (57/158). The mean final dose of captopril was 67 mg/day. Blood pressure (BP) was effectively controlled in 73% of patients (mean fall in systolic BP 29 mmHg, CI 24 to 34, P less than or equal to 0.001; mean fall in diastolic BP 18 mmHg, CI 16 to 20, P less than or equal to 0.001). Blood urea and creatinine rose slightly in all patients (urea by 0.9 mmol/l [13%], CI 0.5-1.3, P less than or equal to 0.001 and creatinine by 9 mumols/l [8%], CI 4-13, P less than or equal to 0.001). Twenty six patients were withdrawn from captopril therapy: 6 because of poor control of their blood pressure, two because it was no longer necessary and 12 (7.7%) because of extrarenal adverse effects--10 for rashes, one each for gastric upset and impotence. Captopril was withdrawn in a further 6 patients, because of deteriorating renal function. Factors discriminating those at risk of renal dysfunction were high doses of captopril, concomitant high dose diuretic therapy and undiagnosed renovascular disease.

The destination and dependency of patients discharged from care of the elderly units in the West Midlands

Between November 1988 and January 1989 a prospective survey was undertaken on patients aged 65 years and over who were discharged from the care of geriatricians in seven District General Hospitals. The survey aimed to provide a regional perspective on patient dependency by relating dependency at discharge to the discharge destination. The findings show that the majority of patients were relatively independent and most returned home. A significant number of the very dependent patients were discharged to the community with private residential and nursing homes making an important contribution to the placement of highly dependent patients.